Glaucoma

Definition

The two major categories of glaucoma are open-angle glaucoma (OAG) and narrow angle glaucoma. The "angle" in both cases refers to the drainage angle inside the eye that controls the outflow of the watery fluid (aqueous) that is continually being produced inside the eye.

If the aqueous can access the drainage angle, the glaucoma is known as open angle glaucoma. If the drainage angle is blocked and the aqueous cannot reach it, the glaucoma is known as narrow angle glaucoma.

Primary open-angle glaucoma. This common type of glaucoma gradually reduces your peripheral vision without other symptoms. By the time you notice it, permanent damage already has occurred.

If your IOP remains high, the destruction caused by POAG can progress until tunnel vision develops, and you will be able to see only objects that are straight ahead. Ultimately, all vision can be lost, causing blindness.

These signs constitute a medical emergency. The attack may last for a few hours, and then return again for another round, or it may be continuous without relief. Each attack can cause progressively more vision loss.

Normal-tension glaucoma. Like POAG, normal-tension glaucoma (also called normal-pressure glaucoma, low-tension glaucoma or low-pressure glaucoma) is a type of open-angle glaucoma that can cause visual field loss due to optic nerve damage. But in normal-tension glaucoma, the eye's IOP remains in the normal range.

Also, pain is unlikely and permanent damage to the eye's optic nerve may not be noticed until symptoms such as tunnel vision occur.

The cause of normal-tension glaucoma is not known. But many doctors believe it is related to poor blood flow to the optic nerve. Normal-tension glaucoma is more common in those who are Japanese, are female and/or have a history of vascular disease.

Pigmentary glaucoma. This rare form of glaucoma is caused by clogging of the drainage angle of the eye by pigment that has broken loose from the iris, reducing the rate of aqueous outflow from the eye. Over time, an inflammatory response to the blocked angle damages the drainage system.

You are unlikely to notice any symptoms with pigmentary glaucoma, though some pain and blurry vision may occur after exercise. Pigmentary glaucoma most frequently affects white males in their mid-30s to mid-40s.

Secondary glaucoma. Symptoms of chronic glaucoma following an eye injury could indicate secondary glaucoma, which also may develop with presence of eye infection, inflammation, a tumor or enlargement of the lens due to a cataract.

Congenital glaucoma. This inherited form of glaucoma is present at birth, with 80 percent of cases diagnosed by age one. These children are born with narrow angles or some other defect in the drainage system of the eye.

Organ

Glaucoma is a disease of the optic nerve, responsible for transmitting the images received by the eye to the brain.

Symptoms

At first, open-angle glaucoma has no symptoms. It causes no pain. Vision stays normal. Glaucoma can develop in one or both eyes.

Without treatment, people with glaucoma will slowly lose their peripheral (side) vision. As glaucoma remains untreated, people may miss objects to the side and out of the corner of their eye. They seem to be looking through a tunnel. Over time, straight-ahead (central) vision may decrease until no vision remains.

Frequency

Causes

Glaucoma usually occurs when pressure in your eye increases. This can happen when eye fluid isn't circulating normally in the front part of the eye.

Normally, this fluid, called aqueous humor, flows out of the eye through a mesh-like channel. If this channel becomes blocked, fluid builds up, causing glaucoma. The direct cause of this blockage is unknown, but doctors do know that it can be inherited, meaning it is passed from parents to children.

Less common causes of glaucoma include a blunt or chemical injury to the eye, severe eye infection, blockage of blood vessels in the eye, inflammatory conditions of the eye, and occasionally eye surgery to correct another condition. Glaucoma usually occurs in both eyes, but it may involve each eye to a different extent.

Evolution

The increased pressure, called intraocular pressure, can damage the optic nerve, which transmits images to the brain. If damage to the optic nerve from high eye pressure continues, glaucoma will cause permanent loss of vision. Without treatment, glaucoma can cause total permanent blindness within a few years.

Diagnosis

Glaucoma is detected through a comprehensive dilated eye exam that includes the following:

Visual acuity test. This eye chart test measures how well you see at various distances.

Visual field test. This test measures your peripheral (side vision). It helps your eye care professional tell if you have lost peripheral vision, a sign of glaucoma.

Dilated eye exam. In this exam, drops are placed in your eyes to widen, or dilate, the pupils. Your eye care professional uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.

Tonometry is the measurement of pressure inside the eye by using an instrument called a tonometer. Numbing drops may be applied to your eye for this test. A tonometer measures pressure inside the eye to detect glaucoma.

Pachymetry is the measurement of the thickness of your cornea. Your eye care professional applies a numbing drop to your eye and uses an ultrasonic wave instrument to measure the thickness of your cornea.

Treatment

Immediate treatment for early-stage, open-angle glaucoma can delay progression of the disease. That’s why early diagnosis is very important.

Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma.

Medicines. Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Taken regularly, these eyedrops lower eye pressure. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye.

Before you begin glaucoma treatment, tell your eye care professional about other medicines and supplements that you are taking. Sometimes the drops can interfere with the way other medicines work.

Glaucoma medicines need to be taken regularly as directed by your eye care professional. Most people have no problems. However, some medicines can cause headaches or other side effects. For example, drops may cause stinging, burning, and redness in the eyes.

Many medicines are available to treat glaucoma. If you have problems with one medicine, tell your eye care professional. Treatment with a different dose or a new medicine may be possible.

Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take, their medicine. You need to use the drops or pills as long as they help control your eye pressure. Regular use is very important.

Tonometer that measures pressure.

A tonometer measures pressure inside the eye to detect glaucoma.

Make sure your eye care professional shows you how to put the drops into your eye. For tips on using your glaucoma eyedrops, see the inside back cover of this booklet.

Laser trabeculoplasty. Laser trabeculoplasty helps fluid drain out of the eye. Your doctor may suggest this step at any time. In many cases, you will need to keep taking glaucoma medicines after this procedure.

Laser trabeculoplasty is performed in your doctor’s office or eye clinic. Before the surgery, numbing drops are applied to your eye. As you sit facing the laser machine, your doctor holds a special lens to your eye. A high-intensity beam of light is aimed through the lens and reflected onto the meshwork inside your eye. You may see flashes of bright green or red light. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better.

Like any surgery, laser surgery can cause side effects, such as inflammation. Your doctor may give you some drops to take home for any soreness or inflammation inside the eye. You will need to make several follow-up visits to have your eye pressure and eye monitored.

If you have glaucoma in both eyes, usually only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart.

Studies show that laser surgery can be very good at reducing the pressure in some patients. However, its effects can wear off over time. Your doctor may suggest further treatment.

Conventional surgery. Conventional surgery makes a new opening for the fluid to leave the eye. Your doctor may suggest this treatment at any time. Conventional surgery often is done after medicines and laser surgery have failed to control pressure.

Conventional surgery, called trabeculectomy, is performed in an operating room. Before the surgery, you are given medicine to help you relax. Your doctor makes small injections around the eye to numb it. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye. This fluid will drain between the eye tissue layers and create a blister-like “filtration bleb.”

For several weeks after the surgery, you must put drops in the eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery.

Conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart.

Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if you have not had previous eye surgery, such as a cataract operation.

Sometimes after conventional surgery, your vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, inflammation, infection inside the eye, or low eye pressure problems. If you have any of these problems, tell your doctor so a treatment plan can be developed.